Anticoagulation for Stroke Prevention in Atrial Fibrillation and Treatment of Venous Thromboembolism and Portal Vein Thrombosis in Cirrhosis

Publication Date: May 30, 2024
Last Updated: June 10, 2024

Atrial Fibrillation in Patients with Liver Disease

We recommend that patients with Child-Pugh A or B cirrhosis with AF and CHA2DS2VASc score of 2 or greater in males and 3 or greater in females be anticoagulated for stroke prevention as per current guideline recommendations in patients without cirrhosis unless otherwise contraindicated. There is inadequate evidence with respect to the benefit and risk of anticoagulation in patients with Child-Pugh C cirrhosis.
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We suggest that patients with Child-Pugh A or B cirrhosis with AF and CHA2DS2VASc score of 1 in males and 2 in females be anticoagulated for stroke prevention as per current guideline recommendations in patients without cirrhosis unless otherwise contraindicated. There is inadequate evidence with respect to the benefit and risk of anticoagulation in patients with Child-Pugh C cirrhosis.
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We suggest that DOACs at standard doses are used in patients with AF and Child-Pugh A or B cirrhosis in preference to VKAs based on available evidence suggesting greater efficacy and safety with DOACs as compared to VKAs.
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There is inadequate in-vivo pharmacokinetic or clinical evidence to recommend for or against specific DOACs for stroke prevention in AF in cirrhosis.
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We suggest a case-by-case consideration of LAAO in select patients with AF and cirrhosis at high risk of stroke who are not candidates for, or who have failed, anticoagulation and who are expected to have a reasonable life expectancy (i.e. patient awaiting transplant).
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Deep Vein Thrombosis/Pulmonary Embolism in Patients with Liver Disease

We recommend patients with cirrhosis and acute DVT/PE are offered treatment with anticoagulation barring a contraindication such as active bleeding, in keeping with current guideline recommendations for patients without cirrhosis.
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We suggest the use of either DOAC or LMWH +/- VKA for patients with Child-Pugh A or B cirrhosis based on patient preference.
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We suggest LMWH alone (or as a bridge to VKA in patients with a normal baseline INR) in patients with Child-Pugh C cirrhosis.
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We suggest anticoagulation should not be withheld in patients with moderate thrombocytopenia secondary to advanced liver disease. A case-by-case decision should be made when the platelet count is <50 x 109 /L, based on site and extent of thrombosis, risk of thrombus extension, patient preference and presence of active bleeding/additional bleeding risk factors.
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Portal Vein Thrombosis in Patients with Cirrhosis

We recommend anticoagulation for all patients with cirrhosis with symptomatic PVT for a minimum of six months.

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We suggest anticoagulation for all patients with cirrhosis with asymptomatic, but progressing PVT for a minimum of six months, unless there are clear contraindications to anticoagulation.
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We recommend continuing extended anticoagulation for all patients with cirrhosis and PVT who are candidates for liver transplantation unless patients are actively bleeding.
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Anticoagulation may be considered in patients with cirrhosis and asymptomatic PVT who are not candidates for liver transplantation on a case-by-case basis as anticoagulation may be associated with a survival benefit. If anticoagulation is initiated, we recommend regular reassessment of bleeding risk (for example at six monthly intervals) and withdrawal of anticoagulation in the event of active bleeding or with significant increase in bleeding risk.
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We recommend evaluating for the presence of varices and ensuring adequate management prior to initiation of anticoagulant therapy and refer to other guidance documents for recommended strategies.
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We suggest the use of either DOAC or LMWH +/- VKA for patients with Child-Pugh A or B cirrhosis.
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We suggest LMWH alone (or as a bridge to VKA in patients with a normal baseline INR) in patients with Child-Pugh C cirrhosis.
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Recommendation Grading

Disclaimer

The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.

Overview

Title

Anticoagulation for Stroke Prevention in Atrial Fibrillation and Treatment of Venous Thromboembolism and Portal Vein Thrombosis in Cirrhosis

Authoring Organization

International Society on Thrombosis and Haemostasis

Publication Month/Year

May 30, 2024

Last Updated Month/Year

June 24, 2024

Document Type

Guideline

Country of Publication

Global

Document Objectives

Whilst advanced liver disease was previously considered to be an acquired bleeding disorder, there is increasing recognition of an associated prothrombotic state with patients being at higher risk of atrial fibrillation (AF) and stroke and venous thromboembolism including portal vein thrombosis (PVT). We review the available literature on epidemiology, pathophysiology and risk factors and provide guidance on anticoagulant management of these conditions in adults with cirrhosis. In patients with Child-Pugh A or B cirrhosis and AF, we recommend anticoagulation with standard dose direct oral anticoagulants (DOACs) in accordance with cardiology guideline recommendations for patients without liver disease. In those with Child-Pugh C cirrhosis, there is inadequate evidence with respect to the benefit and risk of anticoagulation for AF. For patients with cirrhosis and acute deep vein thrombosis or pulmonary embolism, we recommend anticoagulation and suggest use of either a DOAC or low molecular weight heparin/vitamin K antagonist. We recommend anticoagulation for patients with cirrhosis and symptomatic PVT. We suggest anticoagulation for those with asymptomatic, progressing PVT and recommend continuing extended anticoagulation for liver transplant candidates with PVT.

Inclusion Criteria

Male, Female, Adult, Older adult

Health Care Settings

Ambulatory, Hospital, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Treatment, Management, Prevention

Diseases/Conditions (MeSH)

D001281 - Atrial Fibrillation, D000925 - Anticoagulants, D008103 - Liver Cirrhosis, D011169 - Portal Vein

Keywords

atrial fibrillation, anticoagulation, cirrhosis, Stroke Prevention, VTE, Venous Thromboembolism, Portal Vein Thrombosis

Source Citation

Carlin S, Cuker A, Gatt A, Gendron N, Hernandez-Gea V, Meijer K, Siegal DM, Stanworth S, Lisman T, Roberts LN, Anticoagulation for Stroke Prevention in Atrial Fibrillation and Treatment of Venous Thromboembolism and Portal Vein Thrombosis in Cirrhosis: Guidance from the SSC of the ISTH, Journal of Thrombosis and Haemostasis (2024), doi: https://doi.org/10.1016/ j.jtha.2024.05.023.